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Specific challenges in key
population in Romania and in
Central and Eastern Europe
Prof. Adrian Streinu-Cercel MD, PhD, HC
National Institute for Infectious Diseases “Prof. Dr. Matei Balș”,
Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
30-31 January 2019, Bucharest
Disclosures
Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, Romania
No relevant conflicts of interest to declare
in relation to this presentation
Romania – 20 million people
Prevalence Annual Incidence
Comments
HIV1 0.07% 0.002%
725 new cases per year on average during 2007-2017:
• 2007-2010 (538 cases/year) • 2011-2017 (850 cases/year)
HBV 5.6%2 0.001%3 National vaccination: 21-fold
decrease in incidence vs. 1995
HCV 1.9%4 0.0003%3 -
Co-infected HIV/HBV 19.9%5 0.3%1 43.4% in the “Romanian cohort”6
Co-infected HIV/HCV 1.8%6 0.2%1 86.8% of IDUs 1Calculated based on: www.cnlas.ro. Data current through 30 Jun 2017; 2Constantinescu I, et al, Hepat Mon. 2014;14(10): e22072; 3Romanian National Institute for Public Health 2015. http://www.cnscbt.ro/index.php/rapoarte-anuale/; 4RO 19.02 project; 5Juganariu G et al, Rev Med Chir Soc Med Nat Iasi. 2014;118(2):339-45; 6Ruță SM et al, MedGenMed. 2005; 7(1): 68.
Romania
Prevalence of Different Subtype/Genotype in Country
HIV Subtype
Distribution:
Historically: F1 = 95%
New cases: F1 = 77%1, B = 6.3%2, C and A = 16.7% CRF14_BG = 20.3% in IDUs3
1Stanojevic M et al, AIDS Rev. 2012;14(1):28-36 2Paraschiv S et al, Infect Genet Evol. 2012;12(5):1052-7 3Niculescu I, et al. AIDS Res Hum Retroviruses. 2015; 31(5): 488–495. 5Ruță S, et al. J Infect Dev Ctries. 2016 May 31;10(5):523-7
HIV1
Historically: • Epidemiologic accident = 68.9%, • Unknown = 17.4%, • IDU = 0.1%, • Hetero = 0.1%
New cases: • Hetero = 64.5%, • IDU = 15.5%, • MSM = 18%, • MTCT = 0.7%
Romania Main Way of Transmission
1Calculated based on: www.cnlas.ro. Data current through 30 Jun 2017 2Romanian National Institute for Public Health 2015. http://www.cnscbt.ro/index.php/rapoarte-anuale/
HIV1
Historically: • Epidemiologic accident = 68.9%, • Unknown = 17.4%, • IDU = 0.1%, • Hetero = 0.1%
New cases: • Hetero = 64.5%, • IDU = 15.5%, • MSM = 18%, • MTCT = 0.7%
Romania Main Way of Transmission
1Calculated based on: www.cnlas.ro. Data current through 30 Jun 2017 2Romanian National Institute for Public Health 2015. http://www.cnscbt.ro/index.php/rapoarte-anuale/
HIV/AIDS
• It is a book of “Good Clinical Practice”
30-31 January 2019, Bucharest
We started in 1985 with …
• Nothing
• A lot of questions
• A lack of answers
• With empty hands
30-31 January 2019, Bucharest
But …
• With the desire to do something
30-31 January 2019, Bucharest
Challenges During the Time
• Lack of testing
• Lack of therapy
• Low acceptance of diagnosis
• Tender love & care
• Social stigma
• Clinical international trials for the new molecules
30-31 January 2019, Bucharest
Thomson and Najera, JID, 2007; Stanojevic et al. AIDS Rev 2011; www.cnlas.ro
“1987-1990 cohort” children: homogenous F1 subtype of HIV
HIV subtype F predominance,
unique in Europe
Long term survivors – yesterday’s children, today’s parents
No of cases No of cases
Age at diagnosis – cumulative total
1985 - 2010 Current age in 2019
June 2010, HIV/AIDS Monitoring and Evaluation Department of the National AIDS Commission for Romania – “Matei Bals” National Institute of Infectious Diseases
Epidemiology/trends in the WHO European Region 2017 and in Romania 2018
Percentage of new diagnoses in the 19-24 age
group, by EU/EEA countries, 2017
Distribution of PLWHA from the Romanian cohort, by age groups 2018
Source: Compartment for Monitoring and Evaluation of HIV/AIDS Data in Romania– INBI “Prof.Dr.M.Balş”
Sursa: Compartimentul pentru Monitorizarea si Evaluarea Infectiei HIV/SIDA in Romania – INBI Matei Bals 15
Young by age…
…old by treatment
• Antiretrovirals timeline
• Adolescence
• Awareness
• Pediatric to adult transition
• Starting their own family
358 children born during 2006-2012
Number of cases: 1005 Sample: general population
Gender Age
46,5 y.o.
Average
Residence area Educational level
A Streinu-Cercel et all,BMC Infectious Diseases 2016, Volume 16 Suppl 3 DOI 10.1186 s12879-016-1480-8
Knowledge, attitudes and practices of the general population regarding HIV/AIDS, HBV&HCV
Disease awareness How can HCV/HBV be transmitted?
96,1% of respondents heard
about hepatitis B
96,5% of respondents heard
about hepatitis C
97% of respondents heard
about HIV
A Streinu-Cercel et all,BMC Infectious Diseases 2016, Volume 16 Suppl 3 DOI 10.1186 s12879-016-1480-8
Number of cases: 1005/200 Sample: general population/IDUs
Have you ever went through screening for ?
37,4% of respondents
were screened
for hepatitis B/C
85% of respondents
were screened for
hepatitis B/C
HIV Hepatitis
B/C
17,7% of respondents
were screened
for HIV
83% of respondents
were screened
for HIV Number of cases: 1005/200
Sample: general population/IDUs A Streinu-Cercel et all,BMC Infectious Diseases 2016, Volume 16 Suppl 3 DOI 10.1186 s12879-016-1480-8
Estimates UNAIDS Romania 2018
ROMANIASELECTED TRENDS
AIDS Deaths Number of people living with HIV
New HIV Infections Percent of people living with HIV receiving ART
0
100
200
300
400
500
600
700
800
2000 2002 2004 2006 2008 2010 2012 2014 2016
AIDS Deaths
Lower and upperlimits
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
2000 2002 2004 2006 2008 2010 2012 2014 2016
Number of peopleliving with HIV
Lower and upperlimits
0
10
20
30
40
50
60
70
80
2000 2002 2004 2006 2008 2010 2012 2014 2016
Percent of peopleliving with HIV
receiving ART
Lower and upperlimits
0
100
200
300
400
500
600
700
800
900
1,000
2000 2002 2004 2006 2008 2010 2012 2014 2016
New HIV infections
Lower and upperlimits
Sursa: UNAIDS Estimates for Romania 2018
Characteristics of HIV infection cases diagnosed in the WHO European Region in 2017, by geographical areas
* No data received from Germany, Russian Federation, Turkmenistan, Uzbekistan. All data presented were reported to ECDC/WHO through the European Surveillance System (TESSy), except for data for the Russian Federation which were obtained through publicly available national sources [1]. Russian data are included in the numbers in parentheses for the European Region and the East. ** EU/EEA rate is adjusted for reporting delay (Annex 6), the corresponding estimated number of new diagnoses adjusted for reporting delay is (xx xxx/to be updated later).
WHO European Region West Centre East EU/EEA countries
Reporting countries/no. of reporting countries* 49/53 (51/53) 22/23 15/15 12/15 (13/15) 30/31
Number of HIV infection cases 55 018 (159 420) 22 354 6 205 26 459 (130 861) 25 353
Rate per 100.000 population** 8,3 (20,0) 6,4 3,2 23,6 (51,1) 5,8
% of cases:
15-24 age group 9,3% 11,0% 13,7% 6,9% 11,1%
Percentage age 50+ years 16,1% 20,7% 13,1% 13,0% 19,3%
Men/women ration 2,2 2,9 5,8 1,6 3,1
Percentage new diagnoses CD4<350 cells/mm3 53,1% 48,0% 52.5% 57.2% 48,6% Way of transmssion
Heterosexual (men) 25,3% 16,7% 19,4% 33,9% 16,6%
Heterosexual (women) 24,1% 17,5% 7,3% 33,7% 16,5%
MSM 21,2% 39,7% 28,4% 3,9% 38,2%
I.V. drugs 13,0% 2,7% 2,7% 24,1% 3,7%
MTCT 0,7% 0,5% 0,6% 0,9% 0,5%
Unknown 15,4% 22,5% 41,2% 3,4% 24,2%
HCV hotspots ● <2% ● 2-7%
● >=8%
Source: INBIMB 2016
Positive HCV tests
• 3.3% positive anti-HCV tests
• 60.7% of the positive tests had negative HCV-RNA
• 9 counties in Romania were “HCV-free”
3% 3%
5%
6%
8%
0%
10%
4% 4%
5%
0%
10%
7%
1%
4%
1%
2%
7% 5%
7%
3%
2%
4%
0%
3%
0%
3% 3%
0%
7%
9%
0% 0%
7%
12%
6%
4% 3%
1%
3%
0% 0% 0%
3%
6%
9%
12%
15%
Alba Bihor Brăila Călărași Dâmbovița Gorj Iași Mureș Satu Mare Teleorman Vâlcea
=> 1.9%
Source: INBIMB 2016
Progress toward achieving the 1st 90: 90% of all PLHIV who know their status (n=39)
Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data. Latest available data reported, ranging from 2014-2017.
Target reached Above regional average Below regional average
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Global target 90%
Overall percentage 80%
88%
How Math Can Trick You…
• Depends what you compare
How Epidemiology Can Save You…
• Depends of innitial pool of infected individuals
Decreasing estimated time from infection to diagnosis in the EU/EEA
Source: van Sighem, Eurosurveillance, 2017
Median time from infection to diagnosis is
2.9 years
@ECDC_HIVAIDS
Comparison of treatment coverage with year that guidelines on immediate treatment initiation were introduced
89% 86%
68%
0
2
4
6
8
10
12
14
16
18
Introduced by 2014 Introduced by 2016 Introduced by 2018
National treatment policy guidelines
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% diagnosed receiving treatment Number of countries
Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.
“Early adopters of progressive policies and interventions have better outcomes.” Romania - 2001
No further comments your honor !
30-31 January 2019, Bucharest
BUT
30-31 January 2019, Bucharest
Proposed healthcare strategy steps
• Actively promote and implement Early Detection as the foundation for a medically successful treatment and a cost-consciousness approach • Testing/Screening campaign: Randomized screening in general population
(rapid tests) combined with at risk population testing
• Ensure Access, Best-in-Class Treatment, Universality and Equity • Improve access to treatment
• Ensure equitable access and prevent discrimination
• Revise Medical Guidelines
• Revise the collaboration frame between all stakeholders (GPs, specialists, HA, NGO)
• Include Health-Economics in treatment paradigm
Proposed healthcare strategy steps
• Reduction in transmission of the disease through raising awareness
• Ensure public recognition of chronic viral hepatitis with B, C, HIV viruses as an urgent public
health issue by establishing a National Awareness Program on Viral Hepatitis B, C and HIV
transmission routes
• Raise awareness of hepatitis B, C and HIV transmission risks and improve knowledge and skills
for sustaining preventive practices
• Make Hepatitis B, C and HIV a 100% preventable disease with the implementation of the
National Prevention Plan.
• Access the National Registry for viral Hepatitis, HIV, TB, STD… (Surveillance Program)
• Prevention of Biomedical Transmission (Nosocomial)
• Prevention of Mother-to-Child Transmission
• Prevention in PWID
• Prevention in Service Providers
• Prevention in tattooing, piercing, and nail care business
30-31 January 2019, Bucharest
Women and key populations
face even more difficulties
HIV and Aging